Cognitive processing therapy for veterans with military-related posttraumatic stress disorder

Loss of PTSD Diagnosis in Response to Evidence-Based Treatments: A Systematic Review and Meta-Analysis

Importance

In recent decades, evidence-based psychotherapies to treat posttraumatic stress disorder (PTSD) have been developed with robust evidence bases. However, efficacy observed in clinical trials is not always directly applicable to clinical practice.

Objective

To estimate the percentage of patients in both military and veteran (hereafter milvet) and nonmilvet populations that lose their PTSD diagnosis after treatment.

Data Sources

We used the PTSD Repository to identify studies with adults with a DSM-IV/DSM-5 PTSD diagnosis based on a validated assessment. The repository, maintained by the US National Center for PTSD, is continually updated with randomized clinical trials and includes studies published from January 1988 on.

Study Selection

For eligibility, PTSD had to be the primary treatment target, with psychotherapy applied as monotreatment. Eligible studies reported the number of participants who did not meet diagnostic criteria for PTSD posttreatment. When this review was initiated (October 2023), the repository contained 496 unique studies. Data analysis was completed from October 2023 to June 2024.

Data Extraction and Synthesis

The repository follows Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines and uses Cochrane Risk of Bias 2.0. We used mixed-effects logistic regression models to estimate diagnosis loss and incorporated milvet status and sex as covariates.

Main Outcomes and Measures

The primary outcome was the proportion of participants who no longer met criteria for a diagnosis of PTSD posttreatment as assessed by a validated instrument.

Results

We included 34 randomized clinical trials (N = 3208 participants). Point estimates of diagnosis loss across trauma-focused treatments for nonmilvet samples ranged from 65% to 86%. Milvet samples had lower proportions of diagnosis loss in studies of cognitive processing therapy and prolonged exposure compared to nonmilvet samples, ranging from 44% to 50%. There was substantial overlap between the covariates of milvet status and sex. An exploratory analysis identified eye movement desensitization and reprocessing as having the highest proportion of diagnosis loss, but there was substantial heterogeneity, and none of the studies were milvet-focused or conducted in the US. Also, 95% confidence intervals partially overlapped for all trauma-focused treatment estimates.

Conclusions and Relevance

This systematic review and meta-analysis contributes to the substantial literature on psychotherapeutic treatments for PTSD by meta-analyzing the probabilities of diagnosis loss for each psychotherapy. Diagnosis loss data are a relatively straightforward way to discuss potential benefits when initiating a therapy or when discussing potential barriers to progress in treatment.

Bridging the gap of Inequity in Implementation Science: Adaptations of Group EBPs for those with Serious Mental Illness in the Public Sector

There are many group EBPs that are now listed as effective treatments for those with serious mental illness (SMI). Despite this, there are few of these group EBPs that are being delivered consistently in the public sector, causing disparity. This article reviews the challenges that relate to implementation science and those with SMI receiving group EBPs to help them live a life of meaning as they define. The article discusses the need for adaptations of EBPs as individuals with complex concerns need different approaches to implementation science. Next, the article conveys what core constructs of group EBPs have to be maintained as they are and what elements of EBPs need adapting to empower those with SMI in engagement. This article provides knowledge of practical application of implementation science approaches while providing dialectical behavior group therapy and cognitive behavior group therapy for psychosis adaptations for those with SMI in a public sector inpatient setting.

Brain stimulation enhances dispositional mindfulness in PTSD: an exploratory sham-controlled rTMS trial

Objective

Post-traumatic stress disorder (PTSD) is characterized by hypervigilance, intrusive thoughts, negative mood, and avoidant behaviors. Therapies involving mindfulness have been shown to reduce PTSD symptoms and modulate brain function. Pharmacological and brain stimulation interventions are also effective for treating PTSD. Non-invasive repeated transcranial magnetic stimulation (rTMS) of the dorsolateral prefrontal cortex (DLPFC) has been shown to regulate mood and improve PTSD symptoms.

Methods

This is a retrospective chart analysis of data collected pre-treatment, post-treatment, and at three-month follow-up in a single-site, double-blind, sham-controlled trial of right DLPFC rTMS. 31 participants diagnosed with PTSD were recruited for this pilot study. Over two weeks, 19 participants received ten sessions of either 1 Hz or 10 Hz stimulation, and nine received sham treatment.

Results

Participants in the rTMS group had a significant reduction in total Five Facet Mindfulness Questionnaire (FFMQ) scores from baseline to post-treatment, this difference was no longer observed when a false discovery rate (FDR) correction was applied. However, a significant improvement was observed in the rTMS group from baseline to the three-month follow-up in total FFMQ score and nonreactivity. This change in mindfulness scores suggests a potential delay in onset of benefits.

Conclusions

Based on our preliminary data, rTMS may improve levels of dispositional mindfulness and its specific subcomponents. Future studies could investigate brain stimulation to assess its utility for improving mindfulness and related health outcomes to reduce suffering related to PTSD. Moreover, application of this neurostimulation modality for improving mental illness and well-being more generally merits further exploration.

Clinical trial registration

https://clinicaltrials.gov/study, identifier NCT01806168.

Promoting Psychological Health and Overall Wellness in Female Veterans With Military Sexual Trauma Through Complementary Health Interventions: A Quality Improvement Project

INTRODUCTION

Military sexual trauma (MST) has been associated with long-term negative outcomes such as increased rates of cardiovascular disease, post-traumatic stress disorder (PTSD), and suicidal thoughts and behaviors. While evidence supports the effectiveness of psychotherapeutic approaches as treatments for MST and related PTSD symptoms, these interventions have limited impact, attributed to perceived stigma with high dropout rates in female Veterans. Complementary and integrative health (CIH) interventions provide an alternative that may be more acceptable and can help transition Veterans into mental health treatments. Although evidence supports the utility of individual CIH interventions to be both effective and acceptable treatments for MST-related PTSD amongst female Veterans, there are limited evaluations of interventions that combine multiple CIH modalities, specifically in populations of at-risk female Veterans with histories of suicidal ideation or behavior. Thus, this quality improvement (QI) project aimed to assess the impact of a multimodal CIH intervention on mental and physical health symptoms specifically in female at-risk Veterans with MST.

MATERIALS AND METHODS

A total of 19 female Veterans with histories of MST and suicidal ideation and/or behavior who participated in an interventional programming in an urban VA in New York City were included in a secondary analysis for QI evaluation. These female Veterans comprised a subset of participants who previously engaged in a larger QI multimodal CIH intervention delivered over 4-week long in a cohort setting during which Veterans (both males and females) engaged in meditation and mindfulness, physical exercise, nutrition, and motivational curricula. Integrated as part of this programming, mental health symptoms (i.e., depression, PTSD, and stress/anxiety) and other factors related to suicide risk were assessed before and after program participation for all participants. Improvements across these symptoms pre- vs. post-program participation were examined.

RESULTS

For this secondary analysis, a total of 73% of females with MST who participated in the multimodal CIH interventional programming had a prior history of suicidal ideation or behavior. These participants showed elevated levels of depression and sleep disturbance symptoms at baseline prior to engagement in the multimodal CIH interventions, with medium-to-large reductions in these symptoms following completion of the multimodal CIH programming (Cohen's d > 0.61 magnitude differences in symptom reduction pre vs. post).

CONCLUSIONS

The results of this QI evaluation add to the growing body of evidence demonstrating that CIH interventions can be effective in attenuating mental health symptom-related MST and particularly within female Veteran populations at-risk for suicide, underscoring the potential importance of investigating integration of multiple CIH interventions for treatment of at-risk populations in future clinical research studies.

A meta-analytic review of cognitive processing therapy with and without the written account

There are two versions of the Cognitive Processing Therapy (CPT) protocol: one that includes a trauma narrative and one that does not. Despite both versions being used in clinical practice, to date, there has not been a comprehensive comparison of posttraumatic stress disorder (PTSD) treatment outcomes associated with these two protocols. The current study is a meta-analytic review of 29 randomized controlled trials of CPT+A (k = 13) and CPT-C (k = 16) in which we investigated whether there are differences in treatment outcome effect sizes and treatment dropout between the two protocol versions. Sample type (military/veteran versus non-military/non-veteran) as a moderator was examined, given that less robust PTSD treatment outcomes have been typically observed in military and veteran samples. Meta-regression analyses revealed that there were no significant differences between the two CPT protocol versions in pre-post PTSD treatment effect sizes, t(26) = -0.743, p = .463. As expected, studies that enrolled a military or veteran sample reported an average smaller symptom reduction (g = 0.95) than studies that enrolled a non-military or non-veteran sample (g = 1.41), t(26) = 2.48, p = .019. There were also no significant differences between the two CPT protocols for treatment dropout, t(26) = 1.69, p = .104, or between studies enrolling military/veteran and non-military/non-veteran samples t(26) = -1.10, p = .282. The findings support the use of either CPT protocol in practice, but also demonstrate that veterans and service members may be less responsive to either CPT protocol than other trauma samples.

PACAP associated with precise PTSD and fear extinction response in women

Behavioral, biological, and physiological reactions following posttraumatic stress disorder (PTSD) are heterogeneous, particularly between sexes. Pituitary adenylate cyclase-activating polypeptide (PACAP38) is identified as a viable sex-specific marker of PTSD and fear conditioning impairments in women. However, no studies have examined the association between PACAP38 and fear extinction in humans to inform treatment mechanisms, and the association between PACAP38 and PTSD is variable, requiring further investigation. Participants (n = 123) included representative proportions of women (48.8 %), those with ≥subthreshold PTSD (39.8 %), veterans (33.3 %), and participants of color (59.5 %). Main outcomes and measures included PTSD symptoms (CAPS-IV), peripheral serum PACAP38, differential skin conductance response during a fear conditioning paradigm. The Middle-Out Approach was applied to integrate behavioral, biological, and physiological indicators and identify precise clinical phenotypes using latent class analysis. The current study provides behavioral, biological, and physiological evidence of a homogeneous subgroup (13.8 %), composed largely of women, for whom peripheral PACAP38 levels were over twofold higher than other participants (ηp2=.52-.56) and associated with a unique constellation of Intrusive-Hypervigilant PTSD symptoms and impairments in fear extinction retention. Results suggest specificity in the association between PACAP38, PTSD symptoms, and fear extinction retention that can inform practical targets for clinical assessment and intervention, and create viable avenues for future research.

Brexpiprazole and Sertraline Combination Treatment in Posttraumatic Stress Disorder: A Phase 3 Randomized Clinical Trial

Importance

New pharmacotherapy options are needed for posttraumatic stress disorder (PTSD).

Objective

To investigate the efficacy, safety, and tolerability of brexpiprazole and sertraline combination treatment (brexpiprazole + sertraline) compared with sertraline + placebo for PTSD.

Design, Setting, and Participants

This was a parallel-design, double-blind, randomized clinical trial conducted from October 2019 to August 2023. The study had a 1-week, placebo run-in period followed by an 11-week, double-blind, randomized, active-controlled, parallel-arm period (with 21-day follow-up) and took place at 86 clinical trial sites in the US. Adult outpatients with PTSD were enrolled (volunteer sample).

Interventions

Oral brexpiprazole 2 to 3 mg per day (flexible dose) + sertraline 150 mg per day or sertraline 150 mg per day + placebo (1:1 ratio) for 11 weeks.

Main Outcomes and Measures

The primary end point was change in Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) total score (which measures the severity of 20 PTSD symptoms) from randomization (week 1) to week 10 for brexpiprazole + sertraline vs sertraline + placebo. Safety assessments included adverse events.

Results

A total of 1327 individuals were assessed for eligibility. After 878 screen failures, 416 participants (mean [SD] age, 37.4 [11.9] years; 310 female [74.5%]) were randomized. Completion rates were 137 of 214 participants (64.0%) for brexpiprazole + sertraline and 113 of 202 participants (55.9%) for sertraline + placebo. At week 10, brexpiprazole + sertraline demonstrated statistically significant greater improvement in CAPS-5 total score (mean [SD] at randomization, 38.4 [7.2]; LS mean [SE] change, -19.2 [1.2]; n = 148) than sertraline + placebo (randomization, 38.7 [7.8]; change, -13.6 [1.2]; n = 134), with LS mean difference, -5.59 (95% CI, -8.79 to -2.38; P < .001). All key secondary and other efficacy end points were also met. Treatment-emergent adverse events with incidence of 5% or greater for brexpiprazole + sertraline (and corresponding incidences for sertraline + placebo) were nausea (25 of 205 [12.2%] and 23 of 196 [11.7%]), fatigue (14 of 205 [6.8%] and 8 of 196 [4.1%]), weight increase (12 of 205 [5.9%] and 3 of 196 [1.5%]), and somnolence (11 of 205 [5.4%] and 5 of 196 [2.6%]). Discontinuation rates due to adverse events were 8 of 205 participants (3.9%) for brexpiprazole + sertraline and 20 of 196 participants (10.2%) for sertraline + placebo.

Conclusions and Relevance

Results of this randomized clinical trial show that brexpiprazole + sertraline combination treatment statistically significantly improved PTSD symptoms vs sertraline + placebo, indicating its potential as a new efficacious treatment for PTSD. Brexpiprazole + sertraline was tolerated by most participants, with a safety profile consistent with that of brexpiprazole in approved indications.

Trial Registration

ClinicalTrials.gov Identifier: NCT04124614.

Cognitive Processing Therapy for Posttraumatic Stress Disorder in Japan: A Randomized Clinical Trial

Importance

Cognitive processing therapy (CPT) is an evidence-based treatment for posttraumatic stress disorder (PTSD). However, there is little evidence on the efficacy of CPT in East Asia.

Objective

To evaluate whether CPT is effective in treating PTSD among outpatients in a Japanese medical setting.

Design, Setting, and Participants

This randomized clinical trial used a 16-week, single-center, assessor-blinded, parallel-group superiority design to examine the efficacy of CPT in conjunction with treatment as usual (CPT-TAU) vs waiting list with TAU (WL-TAU) from April 2016 through December 2022. The trial included adult patients with PTSD at a national psychiatric referral hospital in Tokyo, Japan. Analysis was based on intention to treat and per protocol and was performed from February 1 to April 30, 2024.

Interventions

Participants were randomized 1:1 to CPT-TAU (n = 29), which consisted of 12 weekly individual CPT sessions, or WL-TAU (n = 31), which consisted of clinical monitoring and/or pharmacotherapy.

Main Outcomes and Measures

The primary outcome was the Clinician-Administered PTSD Scale (CAPS-5) score for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) at 17 weeks. Secondary outcomes included self-reported PTSD symptoms assessed by the PTSD Checklist-5 and responder status at 17 weeks. Adverse events were evaluated using the Japanese version of the Common Terminology Criteria for Adverse Events, version 4.0.

Results

Among 60 eligible participants (all included in the intention-to-treat analysis), mean (SD) age was 36.9 (9.9) years; 54 (90.0%) were women. The CPT-TAU group showed a mean (SE) reduction in CAPS-5 scores of 14.00 (1.92) points, with a low dropout rate (2 of 29 [6.9%]). Patients in the CPT-TAU group showed superiority in all secondary and other outcomes. The mean change difference was observed in depression (8.83; 95% CI, 6.00-11.66), suicidal ideation (6.73; 95% CI, 1.25-12.22), disability (8.16; 95% CI, 3.90-12.43), clinical global impression (0.84; 95% CI, 0.41-1.26), and loss of principal PTSD diagnosis (59.09; 95% CI, 37.19-81.00). There were no serious adverse events in the CPT-TAU group and 3 serious adverse events in the WL-TAU group during the intervention period.

Conclusions and Relevance

In this randomized clinical trial of CPT-TAU vs WL-TAU, CPT was superior in reducing PTSD symptoms. These results strengthen the evidence for use of CPT in East Asian populations.

Trial Registration

Umin.Uc.Jp/Ctr Identifier: UMIN000021670.

Decoding threat neurocircuitry representations during traumatic memory recall in PTSD

The neurocircuitry mechanisms underlying recall of traumatic memories remain unclear. This study investigated whether traumatic memory recall engages neurocircuitry representations that mirror activity patterns engaged during generalized threat stimulus processing in Post Traumatic Stress Disorder (PTSD). Multivariate pattern analysis was used to train 3 decoders. A "trauma" decoder was trained on fMRI patterns during idiographic trauma versus neutral narratives in a sample of 73 adult women with PTSD. A separate cohort of 125 adult participants completed a reward and threat learning task, from which "shock" and "reward loss" decoders were trained on neural patterns during threat or reward outcome delivery, respectively. These decoders were then cross-tested on the alternative datasets, allowing analyses of the degree to which traumatic memory recall engaged neurocircuitry representations that overlap with more general aversive stimuli. Decoders were trained and tested in four networks related to salience processing as well bilateral amygdala and hippocampal masks. The shock decoder trained in a midcingulate / posterior insula network demonstrated elevated predictions for shock during traumatic versus neutral memory recall. Similarly, the trauma decoder made elevated predictions about trauma recall during shock versus no shock delivery across multiple networks related to salience processing. There was no overlap between reward loss decoder predictions and trauma memory recall or vice versa. PTSD participants with elevated re-experiencing symptoms demonstrated the highest engagement of shock activity patterns during trauma memory recall. These results suggest that trauma memory recall engages neurocircuitry representations that overlap with threat, specifically painful, stimulus delivery.

Neural activity during working memory predicts clinical response to computerized executive function training prior to cognitive processing therapy

BACKGROUND

Executive dysfunction, including working memory deficits, is prominent in posttraumatic stress disorder (PTSD) and can impede treatment effectiveness. Intervention approaches that target executive dysfunction alongside standard PTSD treatments could boost clinical response. The current study reports secondary analyses from a randomized controlled trial testing combined PTSD treatment with a computerized training program to improve executive dysfunction. We assessed if pre-treatment neurocognitive substrates of executive functioning predicted clinical response to this novel intervention.

METHODS

Treatment-seeking veterans with PTSD (N = 60) completed a working memory task during functional magnetic resonance imaging prior to being randomized to six weeks of computerized executive function training (five 30-minute sessions each week) plus twelve 50-minute sessions of cognitive processing therapy (CEFT + CPT) or placebo training plus CPT (PT + CPT). Using linear mixed effects models, we examined the extent to which the neurocognitive substrates of executive functioning predicted PTSD treatment response.

RESULTS

Results indicated that veterans with greater activation of working memory regions (e.g. lateral prefrontal and cingulate cortex) had better PTSD symptom improvement trajectories in CEFT + CPT v. PT + CPT. Those with less neural activation during working memory showed similar trajectories of PTSD symptom change regardless of treatment condition.

CONCLUSIONS

Greater activity of frontal regions implicated in working memory may serve as a biomarker of response to a novel treatment in veterans with PTSD. Individuals with greater regional responsiveness benefited more from treatment that targeted cognitive dysfunction than treatment that did not include active cognitive training. Clinically, findings could inform our understanding of treatment mechanisms and may contribute to better personalization of treatment.

Suicide Risk Among Veterans Who Receive Evidence-Based Therapy for Posttraumatic Stress Disorder

Importance

Suicide rates are increased for veterans with posttraumatic stress disorder (PTSD). To inform Veterans Health Administration (VHA) operations, it is important to assess whether suicide risk for veterans differs by receipt of evidence-based treatments.

Objective

To assess suicide risks among veterans in VHA care with new PTSD diagnoses who initiated or received an adequate course of evidence-based psychotherapy (cognitive processing therapy or prolonged exposure [CPT/PE]).

Design, Setting, and Participants

This cohort study of veterans in VHA care evaluated suicide risk through 2020 for veterans with initial PTSD diagnoses during 2016-2019. Data collection and analyses were performed from March 22 to November 22, 2023. The population consisted of veterans who received an initial PTSD diagnosis (preceded by at least 12 months without a PTSD diagnosis) in 2016-2019.

Exposures

Following the index PTSD diagnosis, receipt of a CPT/PE encounter and receipt of an adequate course of therapy (≥8 CPT/PE encounters).

Main Outcome and Measure

Suicide mortality, per death certificate data from the Veterans Affairs/Department of Defense Mortality Data Repository.

Results

Of the population-based sample of 847 217 US veterans, most were male (735 974 [86.9%]); the mean (SD) age was 50.1 (16.3) years. From initial PTSD diagnosis through 2020, there were 1552 suicides. Multivariable proportional hazards regression indicated that initiation of CPT/PE treatment was associated with a 23% lower suicide risk compared with those who did not initiate CPT/PE (hazard ratio [HR], 0.77; 95% CI, 0.59-0.99). Receipt of an adequate course was not associated with suicide (HR, 0.80; 95% CI, 0.55-1.18). Similar results were observed when limiting the cohort to those who received any psychotherapy (n = 552 742; CPT/PE initiation: HR, 0.73; 95% CI, 0.56-0.95; adequate course: HR, 0.77; 95% CI, 0.52-1.12).

Conclusions and Relevance

The findings of this study suggest that, among veterans in VHA care with new PTSD diagnoses, CPT/PE initiation was associated with lower suicide risk. However, for those who initiated CPT/PE, receipt of 8 or more sessions was not associated with added benefit.

Intensive Treatment of Chronic Pain and PTSD: The PATRIOT Program

Military combat can result in the need for comprehensive care related to both physical and psychological trauma, most commonly chronic pain and post-traumatic stress disorder (PTSD). These conditions tend to co-occur and result in high levels of distress and interference in everyday life. Thus, it is imperative to develop effective, time-efficient treatments for these conditions before they become chronic and resistant to change. We developed and pilot-tested the Pain and Trauma Intensive Outpatient Treatment (PATRIOT) Program, a brief, intensive (3 weeks, six sessions) integrated chronic pain and PTSD treatment. An overview and session-by-session outline of the PATRIOT Program is provided, followed by results from the first pilot evaluation of the PATRIOT Program's feasibility, acceptability, and preliminary efficacy in a sample of eight participating Veterans with comorbid chronic pain and PTSD. There were no treatment dropouts. At post-treatment, there were significant reductions in PTSD symptoms based on the Clinician-Administered Assessment of PTSD (CAPS). Pain and catastrophic thinking also decreased from pre- to post-treatment. With continued investigations and support, the PATRIOT Program may offer a brief, cost-effective, and more easily accessible treatment option for individuals who could benefit from learning skills to manage pain and PTSD more effectively.

Web-Based Intervention (SunnysideFlex) to Promote Resilience to Posttraumatic Stress Disorder Symptoms During Pregnancy: Development and Pilot Study

BACKGROUND

Approximately 4% to 8% of pregnant individuals meet the criteria for current posttraumatic stress disorder (PTSD), a known risk factor for a multitude of adverse maternal and child health outcomes. However, PTSD is rarely detected or treated in obstetric settings. Moreover, available prenatal PTSD treatments require in-person services that are often inaccessible due to barriers to care. Thus, web-based interventions offer great potential in extending PTSD treatment to high-risk pregnant individuals by providing affordable, accessible care. However, there are currently no web-based interventions designed specifically for the treatment of PTSD symptoms during pregnancy.

OBJECTIVE

This study aims to develop and pilot a 6-week, web-based, cognitive behavioral therapy intervention for PTSD, SunnysideFlex, in a sample of 10 pregnant women with current probable PTSD. Consistent with established guidelines for developing and testing novel interventions, the focus of this pilot study was to evaluate the initial feasibility and acceptability of the SunnysideFlex intervention and preintervention to postintervention changes in PTSD and depression symptoms. This approach will allow for early refinement and optimization of the SunnysideFlex intervention to increase the odds of success in a larger-scale clinical trial.

METHODS

The SunnysideFlex intervention adapted an existing web-based platform for postpartum depression, Sunnyside for Moms, to include revised, trauma-focused content. A total of 10 pregnant women in weeks 16 to 28 of their pregnancy who reported lifetime interpersonal trauma exposure (ie, sexual or physical assault) and with current probable PTSD (scores ≥33 per the PTSD checklist for DSM-5) were enrolled in the SunnysideFlex intervention. Assessments took place at baseline and 6 weeks (postintervention).

RESULTS

All participants were retained through the postintervention assessment period. Engagement was high; participants on average accessed 90% of their lessons, logged on to the platform at least weekly, and reported a generally positive user experience. Moreover, 80% (8/10) of participants demonstrated clinically meaningful reductions in PTSD symptoms from baseline to postintervention, and 50% (5/10) of participants no longer screened positive for probable PTSD at postintervention. Most (6/10, 60%) of the participants maintained subclinical depression symptoms from baseline to postintervention.

CONCLUSIONS

Findings from this small pilot study indicate that SunnysideFlex may be a feasible and acceptable mechanism for delivering PTSD intervention to high-risk, trauma-exposed pregnant women who might otherwise not have opportunities for services. Larger-scale trials of the intervention are necessary to better understand the impact of SunnysideFlex on PTSD symptoms during pregnancy and the postpartum period.

State of the Science of Cognitive Processing Therapy

This state of the science review provides an overview of the history and findings of cognitive processing therapy (CPT), one of the most recommended treatments for posttraumatic stress disorder, acute stress disorder, and comorbid conditions. After an introduction to CPT and the randomized controlled trials that have been conducted, the effects of CPT on comorbid conditions are reviewed, as well as new combination treatments. Cognitive mediators of change are described. Different formats for CPT that have been developed are described, as well as patient, therapy, and therapist factors in outcome; applicability across diverse populations; efforts to disseminate CPT; and ongoing studies into the future.

A systematic review and meta-analysis of PTSD symptoms at mid-treatment during trauma-focused treatment for PTSD

There is concern that trauma memory processing in psychological therapies leads to PTSD symptom exacerbation. We compared PTSD symptoms at mid-treatment in trauma-focused psychological therapy to control groups. We systematically searched multiple databases and searched grey literature. We included randomised controlled trials involving adults comparing trauma-focused psychological interventions with active non-trauma-focused interventions or waitlist conditions. Twenty-three studies met our inclusion criteria. We found no evidence of PTSD symptom exacerbation at mid-treatment in trauma-focused interventions compared to control groups (g=-.16, [95 % confidence interval, CI, -.34,.03]). Sensitivity analyses with high quality studies (risk of bias assessment ≥ 7; g=-.25; [95 % CI -.48, -.03], k = 12) and studies with passive controls (g=-.32; [95 % CI -.59, -.05], k = 8) yielded small effect sizes favouring trauma-focused interventions. At post-treatment, trauma-focused interventions yielded a medium effect on PTSD symptoms compared to all controls (g=-.57; [CI -.79, -.35], k = 23). Regarding depression, trauma-focused interventions yielded a small effect size compared to controls at mid-treatment (g=-.23; [95 % CI -.39, -.08], k = 12) and post-treatment (g=-.45; [CI -.66, -.25], k = 12). This meta-analysis found no evidence that trauma-focused psychotherapies elicit symptom exacerbation at mid-treatment in terms of PTSD or depression symptoms. Instead, this meta-analysis suggests that the benefits of trauma-focused interventions can be experienced through improved depression and possibly PTSD before the conclusion of therapy. However, it is possible that symptom exacerbation occurred before mid-treatment and/or that people who experience symptom exacerbation drop out of studies and so are not included in the analysis.

Cognitive processing therapy (CPT) versus individual drug counseling (IDC) for PTSD for veterans with opioid use disorder maintained on buprenorphine

BACKGROUND AND OBJECTIVES

There are high rates of comorbidity between posttraumatic stress disorder (PTSD) and opioid use disorder (OUD). Evidence-based trauma-focused psychotherapies such as Cognitive Processing Therapy (CPT) are a first-line treatment for PTSD. Veterans with OUD are treated primarily in substance use disorder (SUD) clinics where the standard of care is drug counseling; they often do not have access to first-line PTSD treatments. This study tested whether CPT can be conducted safely and effectively in veterans with comorbid OUD treated with buprenorphine.

METHODS

This 12-week, 2-site, randomized clinical trial (RCT) included open-label randomization to two groups: (a) CPT versus (b) Individual Drug Counselling (IDC) in veterans with PTSD and comorbid OUD who were maintained on buprenorphine (N = 38).

RESULTS

Veterans randomized to either IDC (n = 18) or CPT (n = 20) showed a significant reduction in self-reported PTSD symptoms over time as measured by the PTSD checklist (PCL-5) but there were no treatment group differences; there was some indication that reduction in PTSD symptoms in the CPT group were sustained in contrast to the IDC group. Recruitment was significantly impacted by COVID-19 pandemic, so this study serves as a proof-of-concept pilot study.

DISCUSSION AND CONCLUSIONS

Veterans with OUD and PTSD can safely and effectively participate in evidence-based therapy for PTSD; further work should confirm that trauma-focused treatment may be more effective in leading to sustained remission of PTSD symptoms than drug counseling.

SCIENTIFIC SIGNIFICANCE

This is the first study to evaluate CPT for PTSD in the context of buprenorphine treatment for OUD.

Dyadic Investigation of Posttraumatic Stress Symptoms and Daily Sleep Health in Patients With Cancer and Their Caregivers

OBJECTIVE

Cancer can be a traumatic experience affecting multidimensional aspects of sleep among patients and caregivers. This study examined the differential associations of cancer-related posttraumatic stress symptoms (PTSS) with various sleep markers in this population.

METHODS

Patients newly diagnosed with colorectal cancer ( n = 138, mean age = 56.93 years, 31.88% female, 60.14% Hispanic, 6.53 months after diagnosis) and their sleep-partner caregivers ( n = 138, mean age = 55.32 years, 68.12% female, 57.97% Hispanic) completed questionnaires assessing the four PTSS clusters (intrusion, avoidance, alterations in arousal and reactivity, negative alterations in cognitions and mood). Participants also completed daily sleep diaries for 14 consecutive days, from which sleep onset latency (SOL), wake after sleep onset (WASO), and sleep duration were derived.

RESULTS

Actor-partner interdependence model revealed that caregivers' greater alterations in arousal and reactivity were associated with their own longer SOL ( b = 15.59, p < .001) and their patients' longer sleep duration ( b = 0.61, p = .014), whereas patients' arousal and reactivity were associated with their caregivers' shorter SOL ( b = -8.47, p = .050). Patients' and caregivers' greater negative alterations in cognitions and mood were associated with patients' longer SOL ( b = 9.15, p = .014) and shorter sleep duration ( b = -0.41, p = .050), respectively. Caregivers' greater intrusion was related to their own shorter SOL ( b = -10.14, p = .004).

CONCLUSIONS

The four PTSS clusters, particularly arousal and reactivity and negative cognitions and mood, have distinct associations with sleep markers individually and dyadically in patients and caregivers affected by cancer. Investigations of psychosocial and biobehavioral pathways underlying these relations are warranted. Tailored trauma treatments and sleep interventions may improve the well-being of this population.

Crisis response planning rapidly reduces suicidal ideation among U.S. military veterans receiving massed cognitive processing therapy for PTSD

Posttraumatic stress disorder (PTSD) is common among U.S. military veterans and is associated with increased risk of suicidal thoughts and behaviors. Crisis response planning (CRP), a brief safety planning-type intervention, has been shown to rapidly reduce suicidal ideation and suicide attempts in emergency and acute care settings. CRP's effectiveness when combined with trauma-focused therapies remains unknown. In this randomized pragmatic clinical trial with one-year follow-up, 157 U.S. military personnel and veterans were randomly assigned to receive CRP or self-guided safety planning (SP) prior to beginning massed cognitive processing therapy (CPT) for PTSD. Among 51 (32.5 % of sample) participants endorsing suicidal ideation at baseline, reductions in the severity of suicidal ideation were significantly larger and faster in CRP (F(11,672)= 15.8, p < .001). Among 106 participants denying suicidal ideation at baseline, 8.5 % of CRP participants versus 11.9 % of SP participants (OR=0.69, 95 % CI=0.19-2.52) reported new-onset suicidal ideation during any follow-up assessment. PTSD symptoms significantly reduced over time with no differences between groups. Results support the effectiveness of CRP for rapidly reducing suicidal ideation and managing suicide risk during outpatient treatment for PTSD.

The top-100 cited articles on post-traumatic stress disorder: a historical bibliometric analysis

This is a bibliometric analysis of the most-cited articles on post-traumatic stress disorder (PTSD) with the objective of identifying citation patterns for researchers, journals, centers, periods, topics, and nations. A search was conducted in Thomson Reuters' WoS Core Collection employing the expression TI = (posttraumatic stress disorder OR post-traumatic stress disorder OR PTSD). The 100 most-cited articles were downloaded, and the relevant data were extracted and analyzed. These studies had a total of 69,649 citations, ranging from a minimum of 360 to a maximum of 6029 citations, with an average of 696.49, a standard deviation of 720.92, mode of 369, and a median of 512. Eighty-eight percent of the most-cited articles on PTSD originated from the USA, with just six cities accounting for 52% of the publications and the Boston area alone responsible for almost one-fifth of the total output. The universities of Yale and Harvard headed the ranking of institutions with larger numbers of highly-cited articles. Female researchers represented 42.3% of all authors, 51% of the first authors, and 48% of the corresponding authors. The proportion of M.D. authors decreased significantly between the 1980-1999 (42%) and the 2000-2019 (27.2%) periods while that of Ph.D. authors increased from 44% to 57.4%. The most studied population was military veterans (28%). Female victims of sexual or physical violence, traumatized children, and adult survivors of childhood abuse were assessed in only 6-7% of the most-cited publications. Ten clinical trials evaluated psychological interventions but only three investigated pharmacotherapy. We concluded that influential research on PTSD remains centralized in the USA. A balanced gender representation in publications was found. There was a heavy reliance on combat veterans as the study population. Few highly-cited studies on the pharmacotherapy for PTSD were identified. Focused efforts are needed to address these challenges.

Randomized controlled trials of mind-body interventions for posttraumatic stress disorder: a systematic review

Mind-body interventions (MBIs) include mindfulness-based interventions (MiBIs), meditation- and mantra-based interventions (MMIs), and movement-based interventions (MoBIs). These approaches have demonstrated preliminary efficacy in improving posttraumatic stress disorder (PTSD) symptoms. However, previous systematic reviews and meta-analyses have noted that this area of research is limited by inadequate comparator conditions, heterogeneity of measurement, and absence of objective outcome measures. For these reasons, an updated review of the highest-quality evidence available is warranted. We used the Agency for Healthcare Research and Quality (AHRQ)-funded evidence tables for the PTSD-Repository to identify relevant studies and assess the risk of bias as follows: The search was conducted between June 2018 and June 2022, and databases included PTSDpubs (formerly PILOTS), Ovid® MEDLINE®, Cochrane CENTRAL, Embase®, the Cumulative Index to Nursing and Allied Health Literature (CINAHL®), SCOPUS, and PsycINFO®. Twenty-six randomized controlled trials met our inclusion criteria. After identifying studies and retrieving risk of bias information from the PTSD-Repository evidence tables, we extracted additional data and synthesized the evidence. The strength of evidence was rated as low for MiBIs and MMIs, largely due to contradicting results, inconsistent use of active versus passive comparators, and high risk of bias. The strength of evidence for MoBIs was rated as moderate due to individual studies consistently favoring the intervention and a relatively large number of studies and participants. Of the 26 included studies, only two included objective outcome measures. Implications for future MBI research and clinical applications for treating PTSD are discussed.

Pretreatment characteristics associated with symptom reduction during group cognitive processing therapy versus exposure therapy for PTSD: an exploratory study of Veterans

Exposure and cognitive-based therapies are both effective for PTSD, but knowledge of which intervention is best for which patient is lacking. This lack of knowledge is particularly noticeable for group treatments, as no study has examined whether responses to different group therapies are associated with different pretreatment characteristics. Here, we explored whether pretreatment levels of three types of psychological characteristics-PTSD symptom clusters, posttraumatic cognitions, and emotion regulation difficulties-were associated with symptom reduction during group-delivered cognitive versus exposure-based PTSD treatment. Participants were Veterans with PTSD drawn from two previous clinical trials: one of group CPT (GCPT; n = 32) and the other of group-based exposure therapy (GBET; n = 21). Growth curve modeling was used to identify pretreatment variables that predicted weekly PTSD symptom changes during each therapy. Higher posttraumatic cognitions at pretreatment predicted steeper PTSD symptom reduction during GCPT but not GBET. Additionally, symptom reduction during each therapy was associated with different pretreatment emotion regulation difficulties: difficulties with goal-directed behavior for GBET and lack of emotional clarity and limited access to emotion regulation strategies for GCPT. These findings suggest that assigning Veterans to a group PTSD therapy that better matches their pretreatment psychological profile might facilitate a better therapeutic response.

Massed cognitive processing therapy for combat-related posttraumatic stress disorder: Study design and methodology of a non-inferiority randomized controlled trial

BACKGROUND

Posttraumatic stress disorder (PTSD) is prevalent among military personnel. Cognitive processing therapy (CPT) is identified as one of the most effective treatments for PTSD, although smaller effects have been found in military populations. High rates of dropout from treatment may contribute to reduced efficacy, and military personnel may face unique barriers to treatment completion. One method of improving efficacy may be to reduce dropout by decreasing the time required to receive a full dose of treatment. This paper describes the design and methodology of the first randomized clinical trial testing whether CPT delivered in an intensive format is non-inferior to standard delivery of CPT.

METHOD

Participants are 140 active duty service members randomized to receive CPT in a 5-day combined group and individual intensive outpatient format (MCPT) or standard CPT (delivered individually twice weekly over 6 weeks). Participants are assessed at baseline, and 1 month, 4 months, and 1 year following the conclusion of the therapy. Reduction in PTSD symptomatology is the primary outcome of interest. Secondary outcomes include comorbid psychological symptoms, health, and functioning. A secondary objective is to examine predictors of treatment outcome to determine which service members benefit most from which treatment modality.

CONCLUSION

If determined to be non-inferior, MCPT would provide an efficient and accessible modality of evidence-based PTSD treatment. This therapy format would improve access to care by reducing the amount of time required for treatment and improving symptoms and functioning more rapidly, thereby minimizing interference with work-related activities and disruption to the mission.

Benchmarking secondary outcomes to posttraumatic stress disorder symptom change in response to cognitive processing and written exposure therapy for posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) has high comorbidity with other psychiatric conditions, including depression, generalized anxiety, and suicidality. Evidence-based treatments (EBTs) for PTSD are effective at reducing PTSD symptoms. However, evidence on the impact of PTSD EBTs on comorbid conditions is mixed and often uses pre-post analyses, which disregards PTSD symptom response. This study replicated and extended prior work on benchmarking quality of life to PTSD symptom response to a broader range of secondary outcomes using a research-based metric of clinically meaningful PTSD symptom change. Ninety-five active duty military members seeking treatment for PTSD participated in a randomized noninferiority trial examining two cognitive behavioral therapies for PTSD: Written Exposure Therapy and Cognitive Processing Therapy. Participants completed clinician-administered and self-rating assessments at baseline and 10 weeks post-first treatment session and were classified as PTSD treatment responders or nonresponders. Data were analyzed using generalized linear mixed effects models with repeated measures with fixed effects of time and PTSD symptom response category. PTSD treatment responders experienced significant improvements in secondary outcomes; nonresponders demonstrated statistically significant, but not clinically meaningful, comorbid symptom change. Our findings provide evidence that successfully treating PTSD symptoms may also positively impact psychiatric comorbidity.

Predictors of dropout in cognitive processing therapy for PTSD: An examination of in-session treatment processes

Dropout rates for treatments for adult posttraumatic stress disorder (PTSD) are high. Process research can reveal client factors during treatment that predict dropout. An observational coding system was used to code client processes in audio-recorded early sessions of cognitive processing therapy (CPT), a gold-standard treatment for PTSD. Data are from a randomized controlled noninferiority trial of CPT and written exposure therapy (WET), with higher rates of dropout in CPT than WET (39.7% vs. 6.4%). Participants in this study were 53 treatment-seeking adults with PTSD who were in the CPT arm of the trial and completed the CAPS-5 at pretreatment and at least one session. Of these, 15 (28.3%) dropped out of CPT early (completing ≤9 sessions) and 38 (71.7%) completed treatment. Sessions were coded with an observational coding system on a four-point scale (0 = absent to 3 = high) for maladaptive trauma-related responses (overgeneralized beliefs, ruminative processing, avoidance), affective engagement (negative emotions, physiological distress), and adaptive processing (cognitive emotional processing). Binary logistic regressions showed that more physiological distress and cognitive emotional processing predicted lower dropout, whereas more avoidance predicted higher dropout. Negative emotion, ruminative processing, and overgeneralization were not significant predictors. These findings highlight potential early indicators of treatment engagement that could be targeted to reduce dropout and perhaps facilitate further therapeutic change.

Study protocol: implementing and evaluating a trauma-informed model of care in residential youth treatment for substance use disorders

Introduction

Comorbidity between Substance Use Disorders and trauma/post-traumatic stress disorder (PTSD) is common, particularly within residential treatment services. Comorbidity is associated with poorer treatment retention and treatment outcomes. Integrated treatment approaches are increasingly recommended but are still under examined in residential treatment services. This study will implement and evaluate a novel model of trauma-informed care (TIC) in a youth (18-35 years) residential substance use treatment service.

Methods and analysis

A single-armed, phase 1 implementation trial will be conducted in one residential treatment service. The model, co-developed with staff, incorporates: (i) workforce development in TIC through staff training and clinical supervision; adaptions to the service (ii) policies, procedures, and physical settings and (iii) treatment program adaptions (in delivery style and content) to be more trauma-informed; (iv) client screening and feedback for trauma and PTSD at service entry; and (v) the provision of support, referral and/or trauma-focused therapy to those with PTSD. Service outcomes will include adherence to the TIC model and client treatment completion. Client substance use and mental health measures will be collected at service entry, and 1-, 3-, 6- and 12-months follow up. Staff outcomes, including workplace satisfaction, burnout, and fatigue, as well as perceptions and confidence in delivering TIC will be collected at baseline, and at 3-, 6-, 12- and 18-months following training in the model. The sustainability of the delivery of the TIC model of care will be evaluated for 12 months using service and staff outcomes.

Ethics and dissemination

The study has received ethical approval by the University of Queensland (Approval number: 2020000949). The results will be disseminated through publication in a peer-reviewed scientific journal, presentations at scientific conferences, and distributed via a report and presentations to the partner organization.Clinical trial registration: ACTRN12621000492853.

Moving toward precision PTSD treatment: predicting veterans' intensive PTSD treatment response using continuously updating machine learning models

BACKGROUND

Considerable heterogeneity exists in treatment response to first-line posttraumatic stress disorder (PTSD) treatments, such as Cognitive Processing Therapy (CPT). Relatively little is known about the timing of when during a course of care the treatment response becomes apparent. Novel machine learning methods, especially continuously updating prediction models, have the potential to address these gaps in our understanding of response and optimize PTSD treatment.

METHODS

Using data from a 3-week (n = 362) CPT-based intensive PTSD treatment program (ITP), we explored three methods for generating continuously updating prediction models to predict endpoint PTSD severity. These included Mixed Effects Bayesian Additive Regression Trees (MixedBART), Mixed Effects Random Forest (MERF) machine learning models, and Linear Mixed Effects models (LMM). Models used baseline and self-reported PTSD symptom severity data collected every other day during treatment. We then validated our findings by examining model performances in a separate, equally established, 2-week CPT-based ITP (n = 108).

RESULTS

Results across approaches were very similar and indicated modest prediction accuracy at baseline (R2 ~ 0.18), with increasing accuracy of predictions of final PTSD severity across program timepoints (e.g. mid-program R2 ~ 0.62). Similar findings were obtained when the models were applied to the 2-week ITP. Neither the MERF nor the MixedBART machine learning approach outperformed LMM prediction, though benefits of each may differ based on the application.

CONCLUSIONS

Utilizing continuously updating models in PTSD treatments may be beneficial for clinicians in determining whether an individual is responding, and when this determination can be made.

P3a amplitude to trauma-related stimuli reduced after successful trauma-focused PTSD treatment

An elevated P3a amplitude to trauma-related stimuli is strongly associated with posttraumatic stress disorder (PTSD), yet little is known about whether this response to trauma-related stimuli is affected by treatment that decreases PTSD symptoms. As an analysis of secondary outcome measures from a randomized controlled trial, we investigated the latency and amplitude changes of the P3a in responses in a three-condition oddball visual task that included trauma-related (combat scenes) and trauma-unrelated (threatening animals) distractors. Fifty-five U.S. veterans diagnosed with combat-related PTSD were randomized to receive either active or sham repetitive transcranial magnetic stimulation (rTMS). All received cognitive processing therapy, CPT+A, which requires a written account of the index trauma. They were tested before and 6 months after protocol completion. P3a amplitude and response time decreases were driven largely by the changes in the responses to the trauma-related stimuli, and this decrease correlated to the decrease in PTSD symptoms. The amplitude changes were greater in those who received rTMS + CPT than in those who received sham rTMS + CPT, suggesting that rTMS plays beneficial role in reducing arousal and threat bias, which may allow for more effective engagement in trauma-focused PTSD treatment.

Group Psychotherapy for Parents of Youth with Pediatric Acute-Onset Neuropsychiatric Syndrome

Parents of children with diagnoses of Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS) may experience significant psychological distress related to their child's severe and relapsing illness and challenges with the traumatic nature of its treatment. No manualized or studied psychological interventions specifically for parents of youth with PANS have existed prior to this study. In this pilot study, we assessed the feasibility, satisfaction, and treatment fidelity of a brief 9-session group therapy intervention for parents based on principles of trauma-focused cognitive behavior therapy (CBT). We hypothesized that, if initially elevated, symptoms of depression, anxiety, and trauma would decrease and participants' utilization of positive coping mechanisms would increase post-intervention. We adapted an existing evidence-based group intervention developed for parents of children with premature infants to target sources of stress and coping in parents of children with PANS. Ten parents participated in the study. The 9-session intervention used a combination of techniques that included cognitive restructuring, coping skills, self-care, and a trauma narrative to address psychological stress, trust, grief, and unwanted emotions. Outcome measures included parental symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD), as well as rating of parental satisfaction with the intervention. The treatment was feasible and deliverable with high fidelity. The intervention was rated as useful and satisfactory by parents (overall average usefulness of 4.54 and satisfaction of 4.71 out of 5.0). Elevated symptoms of PTSD and depression decreased with large effect sizes (Cohen's d = 1.42 and Cohen's d = 1.38, respectively). Participating parents demonstrated significantly more active coping and acceptance behaviors and stances. A brief 9-session group therapy intervention based on principles of trauma-focused CBT was found to be effective in reducing symptoms of psychological distress in parents of children with PANS.

Self-reported sleep problems in active-duty US Army personnel receiving posttraumatic stress disorder treatment in group or individual formats: secondary analysis of a randomized clinical trial

STUDY OBJECTIVES

Sleep disturbances are common in military personnel with posttraumatic stress disorder (PTSD) and may persist following treatment. This study examined service members seeking treatment for PTSD, reporting insomnia symptoms, nightmares, excessive daytime sleepiness, and potential obstructive sleep apnea at baseline and the impact of sleep disturbances on a course of PTSD treatment.

METHODS

In this secondary analysis, sleep was evaluated in 223 service members who participated in a randomized clinical trial comparing Cognitive Processing Therapy for PTSD delivered in individual or group formats. Sleep assessments included the Insomnia Severity Index, the Trauma-Related Nightmare Survey, and Epworth Sleepiness Scale administered at baseline and 2 weeks posttreatment.

RESULTS

Following PTSD treatment, there were significant improvements for insomnia symptoms (MΔ = -1.49; d = -0.27), nightmares (MΔ = -0.35; d = -0.27), and excessive daytime sleepiness (MΔ = -0.91; d = -0.16). However, mean scores remained in clinical ranges at posttreatment. Participants with baseline insomnia symptoms had worse PTSD severity throughout treatment. Participants with baseline excessive daytime sleepiness or probable obstructive sleep apnea had greater PTSD severity reductions when treated with Cognitive Processing Therapy individually vs. in a group. Those with insomnia symptoms, nightmare disorder, and sleep apnea had greater depressive symptoms throughout treatment.

CONCLUSIONS

Insomnia symptoms, nightmares, and excessive daytime sleepiness were high at baseline in service members seeking treatment for PTSD. While sleep symptoms improved with PTSD treatment, these sleep disorders were related to worse treatment outcomes with regards to symptoms of PTSD and depression. Individual Cognitive Processing Therapy is recommended over group Cognitive Processing Therapy for patients with either excessive daytime sleepiness or probable obstructive sleep apnea.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Group vs. Individual Cognitive Processing Therapy for Combat-related PTSD; URL: https://clinicaltrials.gov/ct2/show/NCT02173561; Identifier: NCT02173561.

CITATION

Puriksma KE, Taylor DJ, Wachen JS, et al. Self-reported sleep problems in active-duty US Army personnel receiving posttraumatic stress disorder treatment in group or individual formats: secondary analysis of a randomized clinical trial. J Clin Sleep Med. 2023;19(8):1389-1398.

Perceived key change phenomena of MDMA-assisted psychotherapy for the treatment of severe PTSD: an interpretative phenomenological analysis of clinical integration sessions

Post-traumatic stress disorder (PTSD) is a prevalent psychiatric condition that significantly impacts daily functioning in patients but lacks adequate treatment options. 3,4-methylenedioxymethamphetamine (MDMA) as an adjunct to psychotherapy for the treatment of PTSD has been studied increasingly for the last two decades and has shown promising results through quantitative data. However, few qualitative studies have been conducted to investigate patients' experiences who participate in these trials. This study intends to complement and clarify the quantitative findings resulting from a Phase-II clinical trial for assessing the safety and efficacy of MDMA-assisted psychotherapy for PTSD by using a qualitative approach based on available material of 4 recorded and transcripted integrative sessions per participant. An Interpretative Phenomenological Analysis (IPA) was conducted for 7 participants who met criteria for severe PTSD to develop a deeper understanding of the treatment and its efficacy. Analysis results provided real-life statements from participants that reflect perceived mechanisms of change and showed to what extent their proposed working mechanisms integrate into daily life.

Comparison of behavioral activation-enhanced cognitive processing therapy and cognitive processing therapy among U.S. service members: A randomized clinical trial

Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) frequently co-occur and can cause significant impairment. Data are lacking as to whether interventions targeting both PTSD and MDD may improve treatment outcomes among individuals with this comorbidity compared with existing evidence-based PTSD treatments alone. This randomized trial compared the effectiveness of cognitive processing therapy (CPT) enhanced with behavioral activation (BA+CPT) versus CPT among 94 service members (52 women and 42 men; age M = 28.5 years) with comorbid PTSD and MDD. The primary outcome was clinician-administered depression symptom severity on the Montgomery-Åsberg Depression Rating Scale (MADRS) from pretreatment through 3-month follow-up. Intent-to-treat analyses using multilevel models showed statistically and clinically significant decreases in MADRS scores for both conditions over time, with no significant differences between BA+CPT and CPT. Secondary depression and PTSD symptom outcomes followed a similar pattern of results. For diagnostic MDD and PTSD outcomes using available data, no statistically significant differences between treatments emerged at posttreatment or 3-month follow-up. Sessions attended, dropout rate, and treatment satisfaction did not significantly differ between treatments. Outcomes were comparable for both treatments, suggesting that BA+CPT and CPT were similarly effective psychotherapy options for comorbid PTSD and MDD.

Impact of morally injurious traumatic event exposure on cognitive processing therapy outcomes among Veterans and service members

LAY SUMMARY

Military personnel frequently report actions taken by themselves or others that violate deeply held moral beliefs, which can be experienced as a kind of moral injury. Some have questioned whether existing treatments for posttraumatic stress disorder (PTSD), such as cognitive processing therapy, are effective for those who have been exposed to a morally injurious traumatic event. These analyses demonstrate that active duty service members and Veterans seeking treatment for PTSD who reported potentially morally injurious trauma had PTSD and depression outcomes that were as good as those whose traumas were not primarily seen as morally injurious, suggesting that cognitive processing therapy is an efficacious treatment for PTSD in the context of morally injurious trauma.

Effectiveness of Operation K9 Assistance Dogs on Suicidality in Australian Veterans with PTSD: A 12-Month Mixed-Methods Follow-Up Study

Post-traumatic stress disorder (PTSD) is a pervasive disorder among both current and ex-serving Australian Defence Force (ADF) members. Studies have shown current psychological and pharmacological treatments for PTSD are suboptimal in veterans, with high dropout rates and poor adherence to treatment protocols. Therefore, evaluating complementary interventions, such as assistance dogs, is needed for veterans who may not receive the ultimate benefit from traditional therapies. The present longitudinal mixed-method study examined the effectiveness of Operation K9 assistance dogs among sixteen veterans with PTSD, specifically, their effects on suicidality, PTSD, depression, and anxiety from baseline to 12 months post-matching. Self-reported measures were completed prior to receiving their dog (baseline) and at three time points (3, 6, and 12 months) following matching. The Clinician-Administered PTSD Scale for DSM-5 was used to assess the severity of every PTSD case. Veterans participated in a semi-structured interview 3 months post-matching. Whilst there was a reduction in the proportion of veterans reporting any suicidality, there was no significant change in the probability of veterans reporting suicidality between time points. There was a significant effect of time on PTSD, depression, and anxiety symptoms. Three major themes emerged from qualitative data analysis: life changer, constant companion, and social engagement. Qualitative data suggest assistance dogs can have a positive impact on important areas of daily life and support veterans in achieving some of the prerequisites for health, including access to services, transport, education, employment, and development of new and diverse social and community connections. Connections were key in improving health and wellbeing. This study exemplifies the power of human-animal relationships and adds emphasis to the need to take these seriously and create supportive healthy environments for veterans with PTSD. Our findings could be used to inform public health policy and service delivery, in line with the Ottawa Charter action areas and indicate that for veterans with PTSD, assistance dogs may be a feasible adjunct intervention.

Therapeutic interventions impact brain function and promote post-traumatic growth in adults living with post-traumatic stress disorder: A systematic review and meta-analysis of functional magnetic resonance imaging studies

Introduction

The present systematic review and meta-analysis explores the impacts of cognitive processing therapy (CPT), eye movement desensitization and reprocessing (EMDR), and prolonged exposure (PE) therapy on neural activity underlying the phenomenon of post-traumatic growth for adult trauma survivors.

Methods

We utilized the following databases to conduct our systematic search: Boston College Libraries, PubMed, MEDLINE, and PsycINFO. Our initial search yielded 834 studies for initial screening. We implemented seven eligibility criteria to vet articles for full-text review. Twenty-nine studies remained for full-text review after our systematic review process was completed. Studies were subjected to several levels of analysis. First, pre-and post- test post-traumatic growth inventory (PTGI) scores were collected from all studies and analyzed through a forest plot using Hedges' g. Next, Montreal Neurological Institute (MNI) coordinates and t-scores were collected and analyzed using an Activation Likelihood Estimation (ALE) to measure brain function. T-scores and Hedges' g values were then analyzed using Pearson correlations to determine if there were any relationships between brain function and post-traumatic growth for each modality. Lastly, all studies were subjected to a bubble plot and Egger's test to assess risk of publication bias across the review sample.

Results

Forest plot results indicated that all three interventions had a robust effect on PTGI scores. ALE meta-analysis results indicated that EMDR exhibited the largest effect on brain function, with the R thalamus (t = 4.23, p < 0.001) showing robust activation, followed closely by the R precuneus (t = 4.19, p < 0.001). Pearson correlation results showed that EMDR demonstrated the strongest correlation between increased brain function and PTGI scores (r = 0.910, p < 0.001). Qualitative review of the bubble plot indicated no obvious traces of publication bias, which was corroborated by the results of the Egger's test (p = 0.127).

Discussion

Our systematic review and meta-analysis showed that CPT, EMDR, and PE each exhibited a robust effect on PTG impacts across the course of treatment. However, when looking closer at comparative analyses of neural activity (ALE) and PTGI scores (Pearson correlation), EMDR exhibited a more robust effect on PTG impacts and brain function than CPT and PE.

Effectiveness and comparative effectiveness of evidence-based psychotherapies for posttraumatic stress disorder in clinical practice

BACKGROUND

While evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) is a first-line treatment, its real-world effectiveness is unknown. We compared cognitive processing therapy (CPT) and prolonged exposure (PE) each to an individual psychotherapy comparator group, and CPT to PE in a large national healthcare system.

METHODS

We utilized effectiveness and comparative effectiveness emulated trials using retrospective cohort data from electronic medical records. Participants were veterans with PTSD initiating mental healthcare (N = 265 566). The primary outcome was PTSD symptoms measured by the PTSD Checklist (PCL) at baseline and 24-week follow-up. Emulated trials were comprised of 'person-trials,' representing 112 discrete 24-week periods of care (10/07-6/17) for each patient. Treatment group comparisons were made with generalized linear models, utilizing propensity score matching and inverse probability weights to account for confounding, selection, and non-adherence bias.

RESULTS

There were 636 CPT person-trials matched to 636 non-EBP person-trials. Completing ⩾8 CPT sessions was associated with a 6.4-point greater improvement on the PCL (95% CI 3.1-10.0). There were 272 PE person-trials matched to 272 non-EBP person-trials. Completing ⩾8 PE sessions was associated with a 9.7-point greater improvement on the PCL (95% CI 5.4-13.8). There were 232 PE person-trials matched to 232 CPT person-trials. Those completing ⩾8 PE sessions had slightly greater, but not statistically significant, improvement on the PCL (8.3-points; 95% CI 5.9-10.6) than those completing ⩾8 CPT sessions (7.0-points; 95% CI 5.5-8.5).

CONCLUSIONS

PTSD symptom improvement was similar and modest for both EBPs. Although EBPs are helpful, research to further improve PTSD care is critical.

Treatment of Posttraumatic Stress Disorder Alleviates Tinnitus-Related Distress Among Veterans: A Pilot Study

PURPOSE

Military service personnel are at increased risk for developing tinnitus due to heightened exposure to acoustic trauma. The auditory disorder is the leading service-connected disability among veterans and is highly comorbidly diagnosed with posttraumatic stress disorder (PTSD). The biopsychosocial model illustrates that chronic health conditions are exacerbated or maintained by psychiatric distress. Therefore, alleviation of such psychiatric distress can have beneficial impacts on health conditions, such as tinnitus. The aim of this study was to determine whether individuals with both disorders who receive evidence-based therapy for PTSD will experience decreases in both PTSD and tinnitus-related distress.

METHOD

Veterans with comorbid bothersome tinnitus and PTSD received cognitive processing therapy and were assessed for PTSD, tinnitus-related distress, and depression at baseline and 1 month posttreatment follow-up.

RESULTS

At posttreatment follow-up, participants demonstrated significant decreases in PTSD symptoms compared to their baseline scores. Participants also demonstrated decreased tinnitus-related distress and depression, with high effect sizes.

CONCLUSIONS

This pilot study demonstrated that clinical management addressing psychiatric distress, as associated with PTSD, may simultaneously provide benefit for patients with bothersome tinnitus. Although not statistically significant due to the small sample size, large effect sizes indicate that tinnitus-related distress decreased as a function of receiving evidence-based therapy for PTSD. Future clinical trials should increase sample sizes and compare effects to control conditions.

Clinician Experiences With Telepsychiatry Collaborative Care for Posttraumatic Stress Disorder and Bipolar Disorder

OBJECTIVE

Posttraumatic stress disorder (PTSD) and bipolar disorder are common in primary care. Evidence supports collaborative care in primary care settings to treat depression and anxiety, and recent studies have evaluated its effectiveness in treating complex conditions such as PTSD and bipolar disorder. This study aimed to examine how primary care clinicians experience collaborative care for patients with these more complex psychiatric disorders.

METHODS

The authors conducted semistructured interviews with 22 primary care clinicians participating in a pragmatic trial that included telepsychiatry collaborative care (TCC) to treat patients with PTSD or bipolar disorder in rural or underserved areas. Analysis utilized a constant comparative method to identify recurring themes.

RESULTS

Clinicians reported that TCC improved their confidence in managing medications for patients with PTSD or bipolar disorder and supported their ongoing learning and skill development. Clinicians also reported improvements in patient engagement in care. Care managers were crucial to realizing these benefits by fostering communication within the clinical team while engaging patients through regular outreach. Clinicians valued TCC because it included and supported them in improving the care of patients' mental health conditions, which opened opportunities for clinicians to enhance care and address co-occurring general medical conditions. Overall, benefits of the TCC model outweighed its minimal burdens.

CONCLUSIONS

Clinicians found that TCC supported their care of patients with PTSD or bipolar disorder. This approach has the potential to extend the reach of specialty mental health care and to support primary care clinicians treating patients with these more complex psychiatric disorders.

Predictors of Attrition and Response in Cognitive Processing Therapy for Interpersonal Trauma Survivors with PTSD

With the establishment of empirically validated treatments for posttraumatic stress disorder (PTSD), concerns remain regarding the effectiveness of such treatments in real-world clinical settings. Specifically, premature termination and treatment response limit the effectiveness of these interventions. The current study investigated factors potentially related to premature termination and treatment response in Cognitive Processing Therapy with Account (CPT-A). Participants in this study included 42 women (Mage = 30.70 SDage = 9.40) with PTSD from exposure to interpersonal trauma. Demographic characteristics, pre-treatment symptoms of PTSD and depression, and transdiagnostic factors were examined as predictors of attrition and treatment response. Hierarchical regression and logistic regression models were analyzed to test the variance explained and predictive value of these factors. The present study revealed that age was a significant factor related to dropout from CPT-A whereas baseline PTSD symptom severity was significantly related to treatment response. Results of this study suggest the importance of the interrelationships among pre-treatment predictors as well as the consideration of attrition and treatment response as distinct metrics of treatment outcome. Further, these results inform the application of CPT-A for PTSD in survivors of interpersonal trauma, as consideration of the identified predictors of dropout and non-response at intake may contribute to treatment retention and response.

A Study on the Factors Affecting Anger in Patients With Post-traumatic Stress Disorder

OBJECTIVE

To identify the factors affecting anger in post-traumatic stress disorder (PTSD) patients who underwent Clinician-Administered PTSD Scale (CAPS) and Minnesota Multiphasic Personality Inventory-2 (MMPI-2).

METHODS

We retrospectively reviewed patients who underwent CAPS and MMPI-2 at Veteran Health Service Medical Center, Seoul, Korea. Based on the CAPS score, the patients were divided into the PTSD group (n=46) and the trauma exposed without PTSD group (n=29). After checking the correlation between anger, CAPS, and MMPI-2 scales, logistic regression analysis was performed to identify the risk factors for clinically relevant symptoms.

RESULTS

The PTSD group showed significant differences in schizophrenia-related symptoms, ideas of persecution, aggressiveness, psychoticism, and anger scales compared to the trauma-exposed without PTSD group. There was a significant correlation between anger, CAPS, and MMPI-2 except masculinity/femininity, disconstraint, and MacAndrew Alcoholism-Revised. In particular, anger has been shown to have a substantial connection with paranoia, schizophrenia-related symptoms, ideas of persecution, aberrant experiences, and psychoticism. Multiple regression analysis identified that the only significant risk factor for anger was the negative emotionality/neuroticism scale (odds ratio=1.152, p<0.001).

CONCLUSION

The PTSD group had increased anger compared to the trauma-exposed without PTSD group, and that negative emotions may be a risk factor for PTSD.

Comparing Veterans with Posttraumatic Stress Disorder Related to Military Sexual Trauma or Other Trauma Types: Baseline Characteristics and Residential Cognitive Processing Therapy Outcomes

The Veterans Health Administration (VHA) has called for improved assessment and intervention for survivors of military sexual trauma (MST) to mitigate deleterious sequalae, including posttraumatic stress disorder (PTSD). Research on the impact of MST-related PTSD (MST-IT) on men is limited, and few studies have examined the differential effects of treatment across genders and MST-IT. Additionally, studies have utilized varying definitions of MST (e.g., sexual assault only vs. including sexual harassment), contributing to disparate outcomes across studies. Utilizing data from 343 veterans seeking residential cognitive processing therapy (CPT) for PTSD in VHA, this study examined the impact of MST-IT and gender on differences in demographic characteristics; pre-treatment severity of PTSD (overall and clusters), depression, and negative posttraumatic cognitions (NPCs); and post-treatment severity of these variables after accounting for pre-treatment severity. Results from 2x2 factorial ANOVAs found no differences in pre-treatment depression or overall PTSD by MST-IT, gender, or their interaction; however, MST-IT survivors presented with greater pre-treatment avoidance, global NPCs, and self-blame. Results from hierarchical linear regression models found only pre-treatment symptom severity significantly predicted post-treatment severity for overall PTSD and all NPCs. These findings suggest veteran survivors of MST-IT appear to benefit similarly from CPT delivered in a VHA residential PTSD program compared to veterans with other index traumas, regardless of gender. Although there were minimal post-treatment differences in PTSD and NPCs by MST-IT status and gender, residual symptoms related to negative cognitions and mood appear to differ across gender and MST-IT status. Specifically, in individuals without MST-IT, post-treatment PTSD symptoms of negative alterations in cognition and mood were higher in men than women. Moreover, women with MST-IT reported more symptoms of depression than both men with MST-IT and women without MST-IT. These findings suggest depressive symptoms decrease through residential PTSD treatment differentially by MST-IT status and gender and warrant further examination.

Effects of current treatments for trauma survivors with posttraumatic stress disorder on reducing a negative self-concept: a systematic review and meta-analysis

Background: A negative self-concept is characterised by dysfunctional cognitions about the self and has been suggested to be a key factor involved in the development and maintenance of posttraumatic stress disorder (PTSD). In addition, the current definitions of PTSD according to DSM-5 and the new ICD-11 diagnosis of Complex PTSD (CPTSD) include aspects of negative self-concept in their diagnostic criteria. Objective: The aim of this meta-analysis was to synthesise the currently available evidence on the effects of psychological interventions for PTSD on negative self-concept. Methods: PubMed, PsychINFO, PSYNDEX, PTSDpubs and Cochrane Library were searched for randomised controlled trials (RCTs) of psychological treatments for PTSD symptoms in adults, published up to February 2021. A systematic review and meta-analysis were conducted, with risk of bias assessed by the Cochrane Risk of Bias Assessment Tool. Results: A total of 25 RCTs (N = 2585) were included in the meta-analysis. Results showed that psychological interventions significantly improve a negative self-concept with a moderate to large controlled effect size (k = 30, g = 0.67, 95% CI [0.31, 1.02], p < .001) at post-treatment. Heterogeneity between studies was large but could not be accounted for by moderators included in the current analysis, i.e. different types of interventions (e.g. with vs. without a cognitive restructuring component, trauma-focused vs. not). Conclusions: Current treatments for PTSD are effective in reducing a negative self-concept. However, more research is needed to identify moderators of this effect and identify interventions that are most effective for reducing negative self-concept.

A participant-randomized pilot hybrid II trial of group cognitive processing therapy for incarcerated persons with posttraumatic stress and substance use disorder symptoms: study protocol and rationale

BACKGROUND

Trauma exposure and drug addiction go hand-in-hand for the 2.17 million people who are incarcerated in US prisons; prevalence of both exceed 80% among this population. This manuscript describes the rationale and methods for a participant-randomized effectiveness-implementation hybrid type II pilot trial designed to: 1) examine the effectiveness of Cognitive Processing Therapy group (CPT), an evidence-based psychotherapy for posttraumatic stress disorder (PTSD), for reducing post-release drug use and PTSD symptoms when adapted for and delivered in prisons; and 2) provide data on implementation outcomes associated with the use of implementation facilitation as a strategy for supporting uptake of CPT in prisons.

METHOD

Participants in the effectiveness portion of the trial (N = 120) will be incarcerated men and women who are randomly assigned to one of two group therapies: CPT or a control condition (PTSD coping skills group; PCS). Participants will complete assessment measures three times: pre-treatment, post-treatment, and 3 months following release from incarceration. CPT groups will be led by prison counselors who are receiving implementation facilitation to support their efforts. PCS groups will be led by trained clinicians on the research team. Implementation outcomes will include acceptability, appropriateness, adoption, feasibility, fidelity, and sustainability. After enrollment ends, the research team will monitor CPT sustainment and recidivism outcomes of study participants for one year.

DISCUSSION

This study will lay the groundwork for a larger study of interventions for co-occurring PTSD and SUD in prisons and, critically, inform the development of strategies (such as implementation facilitation) for supporting their uptake in routine practice.

TRIAL REGISTRATION

NCT04007666 , clinicaltrials.gov, 24 June 2019, 02 September 2021.

Box 43, El-Sherouk City, Cairo 11837, Egypt. The Center for Drug Research and Development (CDRD), Faculty of Pharmacy, The British University in Egypt, P.O. Box 43, El-Sherouk City, Cairo 11837, Egypt. Clinical Psychology Clinic, Safwat Elgolf Hospital, Almaza, Nasr City, Cairo, Egypt.", "Clinical Pharmacy Practice Department, Faculty of Pharmacy, The British University in Egypt, P.O. Box 43, El-Sherouk City, Cairo 11837, Egypt. The Center for Drug Research and Development (CDRD), Faculty of Pharmacy, The British University in Egypt, P.O. Box 43, El-Sherouk City, Cairo 11837, Egypt. Clinical Pharmacy Practice Department, Faculty of Pharmacy, Ain Shams University, P.O. Box 11566, Abbasia, Cairo, Egypt.", "The Center for Drug Research and Development (CDRD), Faculty of Pharmacy, The British University in Egypt, P.O. Box 43, El-Sherouk City, Cairo 11837, Egypt. Pharmacology and Biochemistry Department, Faculty of Pharmacy, The British University in Egypt, P.O. Box 43, El-Sherouk City, Cairo 11837, Egypt.", Neuropsychiatry Department, Faculty of Medicine, Ain Shams University, P.O. Box 11566, Abbasia, Cairo, Egypt.. Cognitive Processing Therapy Versus Medication for the Treatment of Comorbid Substance Use Disorder and Post-Traumatic Stress Disorder in Egyptian patients (Randomized Clinical Trial)

"Earlier research has established that posttraumatic stress disorder (PTSD) and substance use disorder (SUD) frequently coexist. Aims: Cognitive Processing Therapy was compared to Sertraline and a placebo in an RCT for treating patients with comorbid SUD and PTSD. Methods: 150 patients with SUD and PTSD were interviewed by clinicians and asked to fill out the Clinician-Administered PTSD Scale (CAPS-5), Posttraumatic Stress Disorder Checklist (PCL-5), Beck Depression Inventory (BDI-II), Timeline Follow Back Interview (TLFB), and Brief Addiction Monitor (BAM). Patients were randomly assigned to the following conditions: CPT (n=50), Sertraline (n=50), or Placebo (n=50). Pretreatment, posttreatment, six and, twelve-month follow-up assessments were conducted. Results: When compared to the sertraline group, CPT resulted in much higher reductions in CAPS scores at posttreatment assessment (d=0.93, p < .000). When compared to the control group, CPT considerably reduced PTSD symptoms (the effect size, d=1.9, p < .000). Sertraline resulted in many significant decreases in CAPS when compared to control groups (the effect size , d=1.11, p<.000). At posttreatment, SUD and depression severity were significantly reduced in both CPT and Sertraline groups. After six and twelve months of follow-up, these differences persisted. Conclusion: Comparatively to the control group, CPT and Sertraline significantly decreased PTSD, SUD, and depression."

A Bayesian perspective on severity: risky predictions and specific hypotheses

A tradition that goes back to Sir Karl R. Popper assesses the value of a statistical test primarily by its severity: was there an honest and stringent attempt to prove the tested hypothesis wrong? For "error statisticians" such as Mayo (1996, 2018), and frequentists more generally, severity is a key virtue in hypothesis tests. Conversely, failure to incorporate severity into statistical inference, as allegedly happens in Bayesian inference, counts as a major methodological shortcoming. Our paper pursues a double goal: First, we argue that the error-statistical explication of severity has substantive drawbacks; specifically, the neglect of research context and the specificity of the predictions of the hypothesis. Second, we argue that severity matters for Bayesian inference via the value of specific, risky predictions: severity boosts the expected evidential value of a Bayesian hypothesis test. We illustrate severity-based reasoning in Bayesian statistics by means of a practical example and discuss its advantages and potential drawbacks.

Four profiles of symptom change in residential Cognitive Processing Therapy

A significant portion of veterans do not respond to evidence-based treatments for PTSD. Therefore, researchers have sought to predict who will respond well to trauma-focused treatment. The present study examined pre- and posttreatment symptom profiles, session-by-session change, as well as demographic and additional diagnostic information to better understand PTSD treatment response. Participants included 332 veterans undergoing residential Cognitive Processing Therapy. Latent profile analyses were computed, and four meaningful profiles emerged: Fast Responders, Steady Responders, Partial Responders, and Minimal Responders. Each profile demonstrated symptom reduction at approximately the same rate in the first half of treatment. Two specific profiles, Steady Responders and Minimal Responders, showed key clinically important differences. Both profiles demonstrated severe pretreatment PTSD symptom severity; however, in the second half of treatment, Steady Responders saw the steepest decrease in symptoms of any of the profiles while Minimal Responders saw less symptom reduction compared to all other profiles. Via a thorough examination, membership in Steady Responders compared to Minimal Responders was not associated with demographic or health variables. Results suggest that pretreatment symptom severity does not necessarily determine a client's posttreatment symptom severity. Pretreatment symptom severity did not determine outcome, though some veterans (Minimal Responders) did not experience the same symptom change and treatment effectiveness. Further identifying the factors that lead to the separation of these groups will add important information for determining treatment selection and potential obstacles to effectiveness.

rTMS/iTBS and Cognitive Rehabilitation for Deficits Associated With TBI and PTSD: A Theoretical Framework and Review

Rehabilitation of cognitive and psychosocial deficits resulting from traumatic brain injury (TBI) continues to be an area of concern in health care. Commonly co-occurring psychiatric disorders, such as major depressive disorder and posttraumatic stress disorder, create additional hurdles when attempting to remediate cognitive sequelae. There is increased need for procedures that will yield consistent gains indicative of recovery of function. Intermittent theta-burst stimulation (iTBS), a form of repetitive transcranial magnetic stimulation, has potential as an instrument that can be tailored to aid cognitive processes and support functional gains. The use of iTBS enables direct stimulation of desired neural systems. iTBS, performed in conjunction with behavioral interventions (e.g., cognitive rehabilitation, psychotherapy), may result in additive success in facilitating cognitive restoration and adaptation. The purpose of this theoretical review is to illustrate how the technical and physiological aspects of iTBS may enhance other forms of neurorehabilitation for individuals with TBI. Future research on combinatorial iTBS interventions has the potential to translate to other complex neuropsychiatric conditions.

A predictive coding account of value-based learning in PTSD: Implications for precision treatments

While there are a number of recommended first-line interventions for posttraumatic stress disorder (PTSD), treatment efficacy has been less than ideal. Generally, PTSD treatment models explain symptom manifestation via associative learning, treating the individual as a passive organism - acted upon - rather than self as agent. At their core, predictive coding (PC) models introduce the fundamental role of self-conceptualisation and hierarchical processing of one's sensory context in safety learning. This theoretical article outlines how predictive coding models of emotion offer a parsimonious framework to explain PTSD treatment response within a value-based decision-making framework. Our model integrates the predictive coding elements of the perceived: self, world and self-in the world and how they impact upon one or more discrete stages of value-based decision-making: (1) mental representation; (2) emotional valuation; (3) action selection and (4) outcome valuation. We discuss treatment and research implications stemming from our hypotheses.